Savings Program Overview - REMICADE
JOB#: 96419
VERSION: R2 DATE: 3/22/2016
CUSTOMER: FIS (IL)
JOB NAME: Janssen CarePath/Remicade (TrialCard) - 36889C001
ISSUER: TrialCard, Inc.
Savings Program P.O. #: 112378 PREVIOUS JOB #:
QUANTITY: 82000
for
eligible
commercially SHIP VIA: BrinksTT SHIP TO: FIS - IL - IL
insured
patients
Valid in US and US Territories
Limited Use Rebate Card
Please call 877-324-2145 for card u No cash access
Pay $5 per infusion* CARD TYPE: MasterCard Debit CARD CONSTRUCTION: F4100 100% PVC Opaque White (Spl
CARD SIZE: 2-1/8" X 3-3/8"
*$20,000
CORE: White 14 mil
maximuFmINIpSHr:oPgolrisahm/Polbishenefit
per
calendar
year.
Terms expire at the enCdOLoOfReTaAcRhGEcTa: Pleronofdar year and may change.
See proBEgIMNrB:aO5m4S3S1r0Pe3OqSuITiIrOeNm: ents below.
5431 0312 3456 7890
5431
VVAALLID TTHHRRUU
11/19
ID 12345678910 BIN 610020 GRP 99990809
ICA: 8908
STOCK #: 36889C001
Get savings oIDn#:y1o12u37r8/o36u88t9-Co00f1-pocket medication costs for REMICADE?. DFeRpOeNnTding on your
health insurMaAnGcSeTRpIPlEa:n2-,TrsacakvHi-nCogUsncmoaateyd Oaveprlpayly toward dedu4 cCotliobr Plreoc,ecsso,M-CpRaeyd,,MaCnYdellocwo, U-.Vin. surance.
SIG PANEL TYPE: MC FIS IL 2.81x.406 CVC2
Program does not cover HOLOGRAM: MasterCard Debit Hologram
HOLOGRAM LOCATION: Holo (Front)
costs
to
give
you
your
infusion.
HOLOGRAM PREMIUM:
VOIDV VOIDV
This is a prepaid card issued by MetaBank? will not earn any interest on the funds. Jan law, taxed, or restricted. Not valid for patie to rescind, revoke, amend, terminate this on back of Savings Program brochure and misuse of cards. Patients: Call 877-CAREP process a COB/split bill claim using patient
Black
MODULE TYPE:
MODULE SIZE:
1INLAY:
Enroll in the Savings Program PRE PERSO:
KEY ID: KMCID:
3 ways to enroll Expiration Details:
This order does not contain any embossing effect on the printed product. FI PDF/Proof demonstrating the impact the embossing will have on the existin appearance, a design adjustment may be necessary, please check with you representative.
NOTES:
By creatingBYaAnPoPRnOliVnAeL OF THIS PROOFB, CyUpSThOoMnEeR ACCEPTS FULL
account
anRIdNECeSLnPUrOoDNlIlNiSnGIBgTILEaItXTTY,
FOR THE GRAPHICS,
C8OC7NO7-SNCTTaRErUeNCPTaTtIOhONF,
THE CARD ADDITIONAL
MyJanssenCAVaILSrLeUPTAHaLtESh,T.TEcERoCmMHSNSOELTOGFOYRSTPHEOCIN(F8IT7CH7A-I2TS2IOP7-RN3OS7,O2A8FN). D AGREES TO
If you can read this, your Adobe Acrobat display settings must be adjusted to properly view this proof. Please follow these instructions:
Open the proof in Adobe Acrobat. Click on Edit in the tool bar along the top, and go to Preferences/Page Display.
You will see a selection that says "Use Overprint Preview." The selection in the box must say "Always."
Am I eligible?
You now should be able to view the PDF correctly. If you are using a program other than Adobe Acrobat, please let us know and we will provide instructions to correct the display settings.
By fax or mail
Complete Patient Enrollment Form
You will activate your card upon receipt
of enrollment confirmation by mail. APPROVED as submitted Make Alterations, send me a new hard copy Make Alterations, Email me a new PDF
CUSTOMER APPROVA
You
may
be
eligible
for
the
JansscTehhniipsCpmarooroedfuPrleaep,trheexsSceaenpvtstintthhgaestetPhxaerocatgclotrucaaamltidoeinfsayignonduasnpaderlelainpagpgoeefatr6eaxnotcarenodolfdthaeesramapanpredtcaacrraudnrccrehe/iplnotcmlayotidounusloeefccaaollntmyvpamer,yegdrraecppiahelincodsir,ncgporlooinvr(asth)te(eemxhcoeedapultltewhmhienannsfuuofiarlacontruccreleer.afIrofcaronrye cishuasnegde)s,
sign nee
REMICADE?. There is no income nroetqesusireecmtioenn(nto.t on the physical proof). CPI will submit a proof to the appropriate association for approval, as required. It is the issuer's responsibility to obtain AT
Janssen CarePath Savings Prograasmhnidpfo3a.nr0dRdiEEnMvporieIcCsesA?-tDo1-0Epp?roeoirsfcdbeunartsinoegfdthaeopnqreusmasnertuidtyni.ocPradrtoeidroeundct(cio?on2s0wt%isll nooonntolbyredagenirnsduondft5iol0ae0ssoignrnloeestdsi)an.pcCplPuroIdvweeildlcmpoarsointotsfa,itwnoimthgoaiuxvitmeaulytemorauvtaioyrnioastu,ioirsnisrne(tfwuuritnsheiiondn2to.sCtaPnId. aCrPdIdweilvl inaotitobnes)lioafb2le.0fo
Other requirements
signed proof. Alterations or changes that were not included in the artwork or the original instructions from customer will be subject to additional charges and NOTWITHSTANDING ANYTHING TO THE CONTRARY: (A) IN NO EVENT WILL CPI CARD GROUP, INC. OR ANY OF ITS SUBSIDIARIES BE RESPONSIBLE FOR IN
? This program is only available toPUinNdITivIViEduDaAlMsAaGgEeS6; AoNrDo(Bld)eIFrTuHsRinOgUGcHomOUmReFrAcUiaLTl o(NrOpTrEi:vEaRtReOhReSaOltNhAinNsAuPrPaRnOcVeEfDoPrRthOOeFirAJRaEnNssOeTnOmUReFdAiUcaLTti)oTnH,EiPnRcOluDdUiCnTgISpDlaEnFsECTIVE, CPI R ahveaailltahbclaerethprroouggrhamsttaotecoanvedrfaedpeoTRrHrEatEPiloLPhAnReCOoaEDlfMtUmhECNceTaTdOrOiecRFaeTAtxOiNocYRnhECacFAnoURgsNDteDSss,,T.sPHTuAEhcRiMhTsSOap,NsrCoEMOYgMerYadPOmOiUcNaiPEsrANenI,TDoSMtFOOeaRRvdaSiTciUlHaaPEibdPDl,LeETIEtFRoSEICCPinTRAIdOVRiEVvEIiPD,dRDEuODeaDlpBsUYawCrYTthO,moUAeL.unLsCteAPoTIaWfnCDPyILIes'LSfteNaOntOPesTTeoBI,OrEoNfRre,EdVWSeePHrtOIeaCNlrHagSnWIoBsvILLeAELrdFnBOmmERiYneROniEsUtPt-RrLfauAStCnOioIdLNnEeG.dRAENMYEPDRYO. DINUNCOT
? Out-of-pocket costs paid by this program may not be submitted as a claim for payment to any third-party payer, pharmaceutical patient assistance foundation, or account such as a Flexible Spending Account (FSA), a Health Savings Account (HSA), or a Health Reimbursement Account (HRA).
? Program terms will expire at the end of each calendar year. Before the calendar year ends, you will receive information and eligibility requirements for continued participation. Program subject to change or discontinuation without notice, including in specific states.
? As a condition of participating in this program, you must ensure that you comply with any co-payment disclosure requirements of your insurance carrier or third-party payer, including disclosing to your insurer the amount of co-payment support you receive from this program. By participating in the program, you are giving permission for information related to your Savings Program transactions, including rebates and any funds placed on or balance remaining on the Savings Program card, to be shared with your healthcare provider(s).
? Before you activate your card, it is important that you understand that you will be asked to provide personal information that may include your name, address, phone number, email address, and information related to your prescription medication insurance and treatment. This information is necessary to permit Janssen Biotech, Inc., the maker of REMICADE?, and companies that work with Janssen Biotech, Inc., including our affiliates and our service providers, to fulfill your request to enroll in the Janssen CarePath Savings Program. We may also use the information you give us to learn more about the people who use REMICADE?, and to improve the information we provide to people who are being treated with REMICADE?. Janssen Biotech, Inc., will not share your information with anyone else except as required by law.
? If you use medical/primary insurance to pay for your medication, you are responsible for submitting a rebate request including an Explanation of Benefits (EOB) to receive payment under the Savings Program. At your direction, your provider may submit the rebate request and EOB on your behalf. Please ensure you and your provider coordinate who will submit the rebate request.
? This program offer may not be combined with any other coupon, discount, prescription savings card, free trial, or other offer for reduced medication cost. The selling, purchasing, trading, or counterfeiting of this card is prohibited. Offer good only in the United States and its territories. Void where prohibited, taxed, or otherwise restricted by law.
Janssen CarePath is in no way an extension of medical treatment provided by healthcare professionals to individual patients. You may discontinue your participation at any time by calling 877-CarePath (877-227-3728).
Janssen Biotech, Inc., is not liable for unintended or unauthorized use of t he Janssen REMICADE? Mastercard? if it is lost or stolen. T he Janssen CarePath Savings Program for REMICADE? Prepaid Mastercard is issued by MetaBank?, Member FDIC, pursuant to license by Mastercard International Incorporated. Mastercard is a registered trademark, and the circles design is a trademark o f Mastercard International Incorporated. Janssen CarePath Savings Program is not a MetaBank product and is not endorsed by them.
Please read the full Prescribing Information, including Boxed Warnings, and Medication Guide for REMICADE?, and discuss any questions you have with your doctor.
2 How to Use Your Savings Program Benefits
How your card can be used depends on the insurance you use to pay for your medication:
If you use your medical/primary insurance to pay for your medication through your doctor, treatment provider, or pharmacy:
? You may use your card to receive a rebate, OR ? You may assign your benefits directly to your treatment provider. Please discuss this option with your provider
How it works:
? Your provider or pharmacy may or may not collect your co-pay, based on your insurance coverage ? You receive your treatment with REMICADE? (infliximab) - Your provider or pharmacy submits your claim to your healthcare insurance provider ? You and your provider receive an EOB statement from your insurance - You are responsible for submitting the EOB to Janssen CarePath Savings Program, or you can request
your provider to submit the EOB on your behalf (see How to submit a rebate request below) ? Janssen CarePath Savings Program reviews your EOB, and issues rebate to your card, to you by check, or to your provider if you have assigned your benefits to your provider
If you use your pharmacy/prescription insurance to pay for your medication from a pharmacy:
? You may use your card (provide your Member ID #, Rx BIN #, and Group #) to receive instant savings off the cost of your medication ? The pharmacy will call to collect your co-pay
Remember to bring your card to your treatment appointment. Your card is not a credit card. There is no charge for your card. If for any reason your provider or pharmacy cannot process your card, please call us at 877-CarePath (877-227-3728). You may be able to submit a Rebate Form to receive a check. Proof of medication payment required.
With a Janssen CarePath online account, you can manage your Savings Program benefits
? Review your available benefits ? Submit Savings Program requests ? View benefit payment transactions ? Receive timely alerts and program updates
Get started now...
Visit
Need Call 877-CarePath (877-227-3728) help? Monday?Friday, 8:00 am?8:00 pm ET
Before the calendar year ends, you will receive information and eligibility requirements for continued participation in the program.
How to submit a rebate request If you have created an online Janssen CarePath Patient Account, you may submit online in your
account. If you would like to receive a rebate check payable to you by mail, you must complete a Rebate Request Form and provide proof of medication payment.
At your request, your provider may submit rebate requests to the Savings Program on your behalf via the Provider Portal or by fax or mail.
Online:
Fax: 877-234-3048
Mail: Janssen CarePath Savings Program 2250 Perimeter Park Drive, Suite 300 Morrisville, NC 27560
Confirm with your provider who will submit rebate requests to the program--you or your provider at your request.
Please read the full Prescribing Information, including Boxed Warnings, and Medication Guide for REMICADE?, and discuss any questions you have with your doctor.
? Janssen Biotech, Inc. 2018 11/18 cp-54222v3
................
................
In order to avoid copyright disputes, this page is only a partial summary.
To fulfill the demand for quickly locating and searching documents.
It is intelligent file search solution for home and business.
Related searches
- overview of starbucks
- starbucks overview of the company
- overview of photosynthesis
- overview of photosynthesis quizlet
- activity overview of photosynthesis
- brief overview of starbucks
- overview of photosynthesis review worksheet
- overview of philosophers beliefs
- overview of photosynthesis 4.2 answers
- overview of photosynthesis worksheet
- brief overview of a meeting
- section 4.2 overview of photosynthesis